Transcript Managed Care Models

Managed Care Models:
The Benefit vs. Cost Balance
Presentation Developed for the
Academy of Managed Care Pharmacy
Updated February 2015
Objectives
• To identify the types of managed care models
• To differentiate the level of control and cost
per model
• To identify the role of pharmacy within these
models
Managed Care Model Types
• Health maintenance organization (HMO)
• Preferred provider organization (PPO)
• Point-of-service plan (POS)
• Integrated delivery system (IDS)
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Characteristics of HMOs
• “Gatekeeper” principle
– Primary care provider (PCP) serves as a gatekeeper and
must authorize all medical services
– Services not authorized by the PCP will generally not be
paid for
– Rationale for gatekeeper is to avoid unnecessary
expenses
• Preferred networks
– Plans will only pay for services provided by healthcare
providers that they have contracted with, aka “In
Network”
– Plans will not pay for “Out of Network” providers
• Patient premiums are generally lower
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Characteristics of PPOs
• No gatekeeper
– Patients can choose their own providers without
having to use a designated PCP
• Preferred networks with some out of network
coverage
– Patient can see any healthcare practitioner they
want, but they are financially incentivized to see
in-network providers
• E.g., Patient pays 10% to see in-network vs. 50% to see
out-of-network
• Patient premiums are generally higher
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Characteristics of Other Models
• Point of Service:
– Hybrid of PPO and HMO
– Members of a POS plan do not make a choice
about which provider to use until the point at
which the service is being used, but physicians may
be at risk or contracted exclusively with the plan
• High-Deductible Health Plans (HDHPs):
– Lower premiums and higher deductibles than a
traditional health plan; a form of catastrophic
coverage
Shift Towards Integrated Models
• Integrated Delivery Systems
– A network of health care organizations all under the
same parent company
– Provide all healthcare services to a group of patients,
such as within a geographic location
– Includes PCPs, physicians, hospitals, pharmacies, and
insurers
• Note: Not all models include all groups
– All working towards the same financial and clinical
goals
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Employer Decision: Benefit Controls vs. Cost
Few Benefit Controls
Higher Cost
Lower Cost
Highly Controlled Benefits
Benefit Control vs. Cost
PPO
POS
HMO
Less Control
Higher Control
Higher Cost
Lower Cost
The Role of Pharmacy
The pharmacy benefit is often outsourced to
Pharmacy Benefit Managers (PBMs)
• PBMs contract with multiple organizations to
manage prescription drug benefits
• PBMs provide clinical and operational program
support
– Formulary management, generic substitution,
manufacturer contracting, drug utilization evalution
• PBMs usually have their own mail order pharmacy
The Role of the Pharmacist in a PBM
• Develop and oversee utilization management
strategies
– Prior Authorizations
– Step Therapy
– Quantity Limitations
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Participate in Pharmacy and Therapeutics Committee
Negotiate rebates with manufacturers
Conduct drug utilizations evaluations
Monitor pipeline and patent expiration
Summary
• There are many different types of managed
care models.
• Each model offers a choice to employers who
buy these services.
• Employers must balance employee choice
with cost when choosing.
• Pharmacists have varying roles within these
managed care model types.
Thank you to AMCP members
Wen Liu & Debbie Meyer for
updating this presentation for
2015